Acknowledgments Rebecca Glover-Kudon, PhD, MSPH Amy DeGroff, PhD, - - PDF document

SLIDE 1

9/10/2012 1 Kristine Gabuten Allen, MPH, CHES

Evaluation Team Program Services Branch

National Breast and Cervical Cancer Early Detection Program’s Patient Care Coordination Demonstration Project

National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control

GASCO Annual Meeting September 8, 2012

Acknowledgments

 Rebecca Glover-Kudon, PhD, MSPH  Amy DeGroff, PhD, MPH  Elizabeth Rohan, PhD, MSW  Kate Roland, MPH  Quanza Brooks-Griffin, MPA

SLIDE 2

9/10/2012 2

Disclaimer

The findings and conclusions in this presentation are those of the presenters and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Objectives

By the end of the presentation, participants will be able to describe:

 the CDC care coordination demonstration

project

 patient navigation measures  common patient barriers addressed through

patient navigation

 components of the implementation evaluation

SLIDE 3

9/10/2012 3

Presentation Outline

 Program background and context  Overview of the funded programs  Logic model  Program models and activities  Measures and evaluation  Lessons learned

BACKGROUND AND CONTEXT

SLIDE 4

9/10/2012 4

National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

 Created by Breast & Cervical Cancer Mortality

Prevention Act of 1990

 Established to provide access to screening and

diagnostic services for underserved women

National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

CA I D OR W A MT W Y UT CO NM TX OK KS NE SD ND MN W I I A I L OH I N KY W V VA NC GA FL AL MS MO AR LA NV MI PA NJ NY CT MA VT NH ME TN SC RI AZ DC DE MD HI HI AK AMERI CAN SAMOA NORTHERN MARI ANA I SLANDS GUAM PUERTO RI CO REPUBLI C of PALAU

Am erican I ndian I nitiative:

Arctic Slope Native Assn, Ltd – North Slope Borough, Barrow, AK Cherokee Nation – Tahlequah, OK Cheyenne River Sioux Tribe – Eagle Butte, SD Kaw Nation – Kaw City, OK Native American Rehabilitation Assn of the Northwest, Inc South Puget Intertribal Planning Agency – Shelton, WA Hopi Tribe – Kykotsmovi, AZ Navajo Nation – Window Rock, AZ Yukon-Kuskokwim Health Corp – Bethel, AK Southeast Alaska Regional Health Consortium – Sitka, AK Southcentral Foundation – Anchorage, AK

6 7 Screening Delivery System s

Source: April 2012 MDE submission

 Since 1991:  >4.2 million women screened  53% are of minority race or ethnic background  >10.4 million breast and/or cervical cancer screening examinations completed  54,276 breast cancers detected  3,113 invasive cervical cancers detected

SLIDE 5

9/10/2012 5

More than just screening and diagnosis

 Program management  Data management  Quality assurance / quality improvement  Professional development  Public education/ Targeted outreach  Patient navigation / Case management

Additional Context

 Patient Protection and Affordable Care Act of

2010

• Full implementation in 2014
• Extends healthcare coverage to previously uninsured

persons

• Ensures greater access to preventive care, including

cancer screening

• Presents opportunity for public health to partner with

larger personal health systems

SLIDE 6

9/10/2012 6

National Prevention Strategy

 Maintain a skilled, cross-

trained, and diverse prevention workforce, including Patient Navigators (PNs) and Community Health Workers (CHWs)

CDC Efforts Around CHW/PN Workforce Development

 CDC CHW Policy Brief  ASTHO Brief  50 of 69 state cancer

control plans include references to:

• CHWs, patient navigators, outreach

workers, community health representatives, promotores, community health advisors, lay health educators, lay health advisors,

• r peer educators.

SLIDE 7

9/10/2012 7

What Defines Patient Navigation?

“Individualized assistance offered to patients, families, and caregivers to help overcome healthcare system barriers, and facilitate timely access to quality health and psychosocial care from pre-diagnosis through all phases of the cancer experience.”

• Association of Oncology Social Workers,

Oncology Nursing Society, and C-Change

http://www.aosw.org/ ; http://www.ons.org/ ; http://c-changetogether.org/

• Nurse Navigators
• Social Work Navigators
• Lay Navigators
• May be Community Health

Workers (CHWs)

• Often supervised by social

worker or nurse

CARE COORDINATION OVERVIEW

SLIDE 8

9/10/2012 8

Project Overview

 Purpose – Demonstrate expanded roles for state health

departments in the early detection of breast and cervical cancer through targeted outreach, patient navigation, and case management

 Objectives

• Create and implement changes in operational systems,

policies, and/or practices to improve coordination of cancer prevention and early detection activities

• Extend existing patient navigation and case management

activities into larger health settings to provide these essential services to additional program-eligible women, not currently covered by NBCCEDP-funded services

Care Coordination Program Grantees

CA ID OR WA MT WY UT CO NM TX OK KS NE SD ND MN WI IA IL OH IN KY WV VA NC GA FL AL MS MO AR LA NV MI PA NJ NY CT MA VT NH ME TN SC RI AZ DC DE MD HI HI AK

Care Coordination Grantees

Alabama Colorado Connecticut Maryland NewJersey SouthDakota Louisiana NewYork Texas Virginia Wisconsin

SLIDE 9

9/10/2012 9

LOGIC MODEL

IF we conduct these activities THEN we expect these outcomes

Inputs Activities Immediate Outputs Short-Term Outcomes Intermediate Outcomes Long-term Outcomes

CDC Funds and Technical Support NBCCEDP Care Coordination Supplemental Resources

• Grantee institution

infrastructure (e.g., resources, staff, expertise)

• Grantee Partners

Infrastructure/System

• Work with new health care

providers

• Support systems & policy

change within health care delivery system Patient Navigators

• # / type PNs employed
• PN supervision provided
• # trained / # training
• satisfaction with training

Patient Navigators

• Competent & culturally

sensitive PNs

• Increased knowledge of

community & health care system

• Increased knowledge of breast

and cervical cancer

• Increased skills for delivering

navigation activities Navigated Patients

• Increased access to health

care coverage

• Increased access to screening

and diagnostic services

• Reduced barriers to care
• Increased adherence to

screening/diagnostic/treatment recommendations

• Reduced no-show rate for

appointments

• Improved timeliness for

diagnostic resolution and treatment initiation

• Reduced lost-to-follow-up
• Improved patient and provider

satisfaction

• Increased screening prevalence

within health care setting

• Increased cost efficiencies

Reduced &/or eliminated health disparities Improved disease-specific

• utcomes

Decreased morbidity & mortality due to breast and cervical disease Contextual & External Factors Broader NBCCEDP program, grantee institutional setting; partner organizations; service delivery context; unexpected positive and negative events during project (e.g., changes in Medicare/Medicaid funding; other navigation programs)

NBCCEDP Care Coordination Logic Model

• Increased access and

adherence to breast and cervical cancer screening, diagnostic services, and cancer care for patients experiencing health disparities

• Improved coordination of

care among & between public health, medical, social service, & community personnel/providers

• Improved adherence to

screening guidelines

• Improved screening

prevalence in communities Patient assessment and barrier identification (geographic, language, cost, education, cultural, anxiety, fatalism) Patient education Resolution of patient barriers Data collection and reporting Patient tracking and follow-up Patient outreach and recruitment Navigated Patients

• #/type of outreach activities
• # recruited for navigation
• Patient demographics
• # patients assessed
• # navigated for screening
• # navigated for diagnosis
• #/type of barriers identified
• # / type (individual, group)
• f education delivered
• # / type of PN activities

delivered to reduce barriers

• Time spent to navigate
• # / type of reminders

provided; # patients tracked

• Data collected and reported

(e.g., # assessment forms completed, # PN log forms completed) Patient Navigators

• Qualified PN Staff retained
• Program able to recruit

and supervise qualified PNs Patient Navigation Patient Navigators

• PN recruitment and

employment

• PN training design and

delivery Infrastructure/System

• # / type of expanded health

care settings

• # / type systems/policy

change Infrastructure/System

• Expanded and integrated PN

programs in community Infrastructure/System

• Sustainable PN

programs in community

SLIDE 10

9/10/2012 10

CHARACTERISTICS OF PROGRAM MODELS Priority Populations

 Specific populations identified

• Race/ethnicity
• Rural populations

 Example

• Women in rural areas
• American Indian populations

SLIDE 11

9/10/2012 11

Geographic Reach

Type Grantee City MD County AL, MD, NJ Region LA, NY, TX, VA, WI State CT, CO Reservation SD

Program Setting

 Federally Qualified Health Centers  County Health Departments  Community Clinics  Hospitals  University Health Systems  Urban Indian Health Clinics

SLIDE 12

9/10/2012 12

Patient Barriers

 Geographic  Financial  Language/cultural  Education  Other (fear, environmental issues, negative

past experiences)

ACTIVITIES

SLIDE 13

9/10/2012 13

Grantee Activities

 Program development

• Award Dissemination
• Staffing
• Partnership Development & Management

 Program implementation

• Patient Navigation & Data Management Training
• Data Systems Development & Refinement
• Instituting Policy/Operational Changes
• Delivering Care Coordination Services

 Program monitoring

• Performance measures
• Evaluation

CDC Technical Assistance

 Developed a grantee listserv for information

sharing and communications

 Individual site calls  Technical assistance and consultation

• PSB Program Consultants
• PSB Care Coordination workgroup

 Scheduled networking events  Hosted webinars

SLIDE 14

9/10/2012 14

Monitoring and Evaluation

 Developed performance measures in

collaboration with grantees

 Data reporting tool  Site visit with 2 sites

MEASURES

SLIDE 15

9/10/2012 15

Developing Measures

 Adapted from existing measures used in

NBCCEDP

 Reflects the navigation process and patient

flow

 Emerges from the logic model

Examples of Process Measures

Category of Measurement Potential Measures Potential Data Source

Infrastructure / system Number and type of health care settings where PNs are placed Number and type of systems or policy changes instituted Program records Navigator staff Number and type of navigators hired or moved to care coordination program Staff records Navigator training Number of trainings provided for patient navigation Number of people trained for patient navigation Participant satisfaction with training Knowledge and skills of navigators Training records Pre-post survey of participants Patient outreach and recruitment Number and type of outreach and recruitment activities Number of people recruited for navigation Program records Patient assessment and barrier identification Number of patients enrolled and assessed Socio-demographics of patients Number of patients navigated for screening Patient records Patient assessment forms and patient navigation plans

SLIDE 16

9/10/2012 16

Examples of Short-term Outcome Measures

Category of Measurement Potential Measures Potential Data Source

Infrastructure / system Extent of integrated PN programs in community Program records Navigator staff Navigator staff retention rate Knowledge and skills of navigators Staff records, periodic assessment of navigator skills and knowledge Adherence to screening or diagnostic test Percent of patients navigated who complete their screening or diagnostic test Medical records No-show appointments Percent of navigated patients who miss scheduled appointment for screening or diagnostic exam Medical records, navigator tracking system Timeliness of screening test, diagnostic test, and cancer treatment initiation Average (or median) number of days between referral for screening and screening completion Average (or median) number of days between abnormal screening result and diagnostic completion Average (or median) number of days between diagnosis and initiation of cancer treatment services Medical records

Performance Measures

Category of Measurement Proposed Measures Goal Infrastructure / Systems Description of operational and policy changes that improve coordination of breast and cervical cancer screening / diagnostics care N/A Navigation Targets The percentage met of the annual projection for the number of patients to be enrolled, assessed, and navigated >80% Patient Assessment The percentage of patients enrolled for navigation receiving a formal assessment to identify patient barriers and needs >95% Clinic screening prevalence Percent of age-eligible patients within the clinic census who are up-to-date on breast and cervical cancer screening >80%

SLIDE 17

9/10/2012 17

Performance Measures

Category of Measurement Proposed Measures Goal Breast Cancer Diagnostic Measures Percentage of navigated patients with abnormal screening results with complete diagnostic follow-up >90% Percentage of navigated patients with abnormal screening results with time from screening test result to final diagnosis > 60 days <25% Median number of days between abnormal screening result and diagnostic completion Percentage of navigated patients diagnosed with breast cancer with treatment started >90% Percentage of navigated patients diagnosed with breast cancer with time from date of diagnosis to treatment started >60 days <20% Median number of days between diagnosis and initiation

• f cancer treatment services

Percentage of navigated patients with abnormal screening results lost-to-follow-up <10%

• Yellow shaded measures are performance measures used for the NBCCEDP

Performance Measures

Category of Measurement Proposed Measures Goal Cervical Cancer Diagnostic Measures Percentage of navigated patients with abnormal screening results with complete diagnostic follow-up >90% Percentage of navigated patients with abnormal screening results with time from screening test result to final diagnosis >90 days <25% Median number of days between abnormal screening result and final diagnosis Percentage of navigated patients diagnosed with cervical neoplasia (CIN2, CIN3, CIS) or invasive carcinoma with treatment started >90% Percentage of navigated patients diagnosed with cervical neoplasia (CIN2, CIN3, CIS) with time from date of diagnosis to treatment started > 90 days <20% Median number of days between diagnosis and initiation of treatment for CIN2, CIN3, CIS

SLIDE 18

9/10/2012 18

Performance Measures

Category of Measurement Proposed Measures Goal Cervical Cancer Diagnostic Measures Percentage of navigated patients diagnosed with invasive carcinoma with time from date of diagnosis to treatment started >60days <20% Median number of days between diagnosis and initiation of cancer treatment services Percentage of navigated patients with abnormal screening results lost-to-follow-up <10%

EVALUATION

SLIDE 19

9/10/2012 19

Implementation Evaluation

 Standard data reporting tool

• 11 grantees
• Narrative on program development, implementation,

and continuation

• Measures and data system
• Aggregate data on navigated patients
• Description of navigator background and training

SLIDE 20

9/10/2012 20

SLIDE 21

9/10/2012 21

Implementation Evaluation

 In-depth site visits

• Two grantees
• Two-day site visits in May and June 2012
• Interviews with stakeholders
• Facilitators and challenges
• Accomplishments and lessons learned

LESSONS LEARNED

SLIDE 22

9/10/2012 22

Challenges

 Staffing/Contracting

• Delays

 Implementation

• Start-up longer than anticipated
• Issues with identifying women comparable to the B/C

program

Challenges

 Data

• Data system incompatibility
• Missing data
• Development of standard data definitions
• Data sharing for patient tracking and navigation

SLIDE 23

9/10/2012 23

Accomplishments

 Developed new partnerships

• Federally Qualified Health Centers and Community

Health Centers

• Screening resources

 Local-level networking among health systems  Increased access to screening  Developed and improved data systems  Enhanced data use and data quality

Accomplishments

 Better understanding of patient barriers  Identification of key resource / service gaps  Integration of care coordination with clinical

care

 Using PN model for other chronic disease areas

SLIDE 24

9/10/2012 24

Next Steps

 Completion of the implementation evaluation  Final project report

Future Directions

 Improving Public Health-Primary Care

partnerships

 Establishing standard data variables for patient

navigation in cancer screening programs

 Supporting high quality training for navigators  Promoting care coordination as public health

practice

 Leveraging public health strengths

SLIDE 25

9/10/2012 25

For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

For additional information contact:

National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control

Kristine Gabuten Allen Kgabuten@cdc.gov 770-488-8294